Black men’s awareness of peripheral artery disease and acceptability of screening in barbershops: a qualitative analysis

Introduction Peripheral artery disease (PAD) disproportionately burdens Black Americans, particularly Black men. Despite the significant prevalence and high rate of associated morbidity and mortality, awareness of and treatment initiation for PAD remains low in this demographic group. Given the well-established social cohesion among barbershops frequently attended by Black men, barbershops may be ideal settings for health screening and education to improve awareness, early detection, and treatment initiation of PAD among Black men. Methods A qualitative study involving 1:1 participant interviews in Cleveland, Ohio assessed perspectives of Black men about barbershop-based screening and education about PAD. Inductive thematic analysis was performed to derive themes directly from the data to reflect perceived PAD awareness and acceptability of screening in a barbershop setting. Results Twenty-eight African American/Black, non-Hispanic men completed a qualitative interview for this analysis. Mean age was 59.3 ± 11.2 years and 93% of participants resided in socioeconomically disadvantaged zip codes. Several themes emerged indicating increased awareness of PAD and acceptability of barbershop-based screenings for PAD, advocacy for systemic changes to improve the health of the community, and a desire among participants to increase knowledge about cardiovascular disease. Conclusions Participants were overwhelmingly accepting of PAD screenings and reported increased awareness of PAD and propensity to seek healthcare due to engagement in the study. Participants provided insight into barriers and facilitators of health and healthcare-seeking behavior, as well as into the community and the barbershop as an institution. Additional research is needed to explore the perspectives of additional stakeholders and to translate community-based screenings into treatment initiation. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14648-x.


Background
Peripheral artery disease (PAD) is a morbid form of cardiovascular disease (CVD), most commonly referring to obstruction of the lower extremity arteries. Disease ranges in severity from asymptomatic or intermittent claudication to severe, limb-threatening disease known as chronic limb threatening ischemia (CLTI) [1,2]. A diagnosis of PAD confers increased morbidity and mortality due to increased risk of myocardial infarction, ischemic stroke, limb loss, and death due to CVD. It is estimated to have contributed to roughly 500,000 years lived with disability and 1,000,000 years of life lost globally in 2019 [3]. Individuals living with PAD report poorer quality of life due to pain and discomfort, limited ability to engage in physical activity, depressive symptoms, and feelings of hopelessness [4]. Additionally, the disease and its associated morbidity is costly; it is estimated that US adults with PAD have higher healthcare-related expenditures compared to the general population [5]. Despite these poor outcomes, only 25% of Americans are familiar with PAD -the lowest recognition of all the CVD categories [6,7].
Globally, the data for PAD prevalence among different ethnic and racial groups are limited; however, it is known that high-income countries such as the United States and the United Kingdom have higher rates of PAD compared with low-and middle-income countries (7.4% prevalence of PAD in high-income countries vs. 5.1% in low-and middle-income countries) [8,9]. Further, Black men in the United States have the highest rates of PAD, with an estimated lifetime risk of developing PAD of 30% among Black Americans compared to only 20% among non-Hispanic white Americans [10]. Yet, Black Americans have the lowest reported awareness of PAD compared to other racial or ethnic groups with only 6% of Black Americans being aware of the morbid consequences of PAD [11]. Therefore, early detection and appropriate intervention for PAD among Black men is essential for reducing health disparities.
PAD is often underdiagnosed and undertreated, especially among Black Americans who present with more severe disease and experience worse health outcomes [12][13][14][15]. Black men are less likely to be treated for PAD or its predisposing conditions (e.g., smoking, hypertension, hyperlipidemia), less likely to undergo revascularization as limb salvage therapy for CLTI, more likely to experience lower limb amputation, and ultimately more likely to die from cardiovascular events [16][17][18][19][20][21][22]. These adverse health outcomes are associated with social and economic burden to both the individual and society [23,24].
Race is often conceptualized as an independent risk factor for disease; however, emerging scholarship validates race as a mediator of structural inequalities resulting from racist policies [25]. Systemic racism reinforces policies and practices that operate within and across institutions to reinforce segregation and disadvantage people of color, namely Black Americans. For example, redlining, a practice whereby the federal government sponsored neighborhood rating of desirability to inform home lending, led to segregation by race and differences in neighborhood quality, community conditions, and racial differences in socioeconomic status [26][27][28]. To this day, living in historically redlined and underinvested neighborhoods is associated with adverse health conditions [26]. Inequities in housing, income, education level, and access to quality healthcare, resulting in part from systemic racism [29], can disadvantage underserved populations such as Black Americans, complicating both prevention and management of CVD, including PAD [19,30,31].
At the interpersonal level, Black Americans experience racism and discrimination in various settings, including in healthcare. Although well-intentioned, most healthcare providers hold negative implicit biases toward people of color, which may negatively impact patientprovider interactions, treatment, and health outcomes [32]. Further, historical exploitation and injustices against Black Americans in medicine and research (e.g., The U.S. Public Health Service Syphilis Study at Tuskegee) compound distrust of public health and medical institutions [33], which may impact an individual's propensity to engage with healthcare or research. Beyond physical access to healthcare, "access" may be further envisioned to include mitigation of providers' implicit biases, and validation of Black Americans' historical mistrust of healthcare to build trust to prevent, detect, and treat CVD.
Barbershops are cultural institutions among Black men and allow for open discussion about various topics. Previous studies demonstrate the effectiveness of barbershopbased education and screening in increasing knowledge about various health topics, promoting healthy behaviors and adherence to treatment, and improving blood pressure management [34][35][36][37][38][39]. Given that Black men are less likely than other racial groups or Black women to access healthcare [40], and that barbershops are frequently visited among Black men and ideal for ethnographic exploration [34,41], barbershops may be an ideal setting to improve PAD awareness among Black men. This qualitative study aimed to explore the acceptability of performing PAD screenings in the barbershop setting. To our knowledge, this is the first study to screen for PAD in a barbershop setting and conduct an in-depth examination of participants' perspectives. Coy et al. BMC Public Health (2023) 23:46

Study design
This qualitative sub-study was part of a larger pilot study approved by the University Hospitals Cleveland Medical Center Institutional Review Board [42]. The aims of this sub-study were: 1) assess the acceptability of barbershop-based screening for hypertension and PAD, and 2) assess perceived awareness of PAD among Black men. The design and methods of the pilot study have been published elsewhere. In brief, both a manual Doppler and an automated device were used for measurement of the ankle-brachial index (ABI) to screen for PAD, in accordance with the published standards [42]. To explore the perceived acceptability of the study intervention, our team performed thematic analysis of interviews conducted at participants' final study visit.

Study population and recruitment
The pilot study took place in two Black-owned barbershops in Cleveland, Ohio between June and December 2020. No relationship between study staff and participants had been established prior to study commencement. Barbershop patrons were approached (n = 98) by a study team member for eligibility screening to obtain a convenience sample. Eligible patrons (n = 74) identified as African American or Black and non-Hispanic men, were between the ages of 40 and 89, and regularly attended the barbershop. Thirty-seven eligible participants agreed to participate in the pilot study and signed written informed consent. Patrons who declined to participate did so primarily due to time constraints, not wanting to participate in research, or because they already knew their health status.

Study visits
Study participants completed an initial screening visit and underwent blood pressure and PAD screening using an automated ABI device, followed by a visit 4-6 weeks later when ABI was obtained using the gold-standard Doppler-based methods [43]. Fingerstick cholesterol and glucose readings were also obtained at the second visit. Participants were invited to watch an educational video about PAD following the second visit. A final visit took place 4-6 weeks after the second visit where interviews were conducted. Participants were compensated $100 over the duration of the study, including $80 cash and a $20 restaurant gift card.

Interview
Participants were invited to participate in an interview at the final visit. A qualitative interview guide (see Additional file 1) was developed to explore perspectives on different facets of the intervention. One-on-one interviews were conducted in a private area of the barbershop primarily by investigator TC (white male-identified) and lasted roughly 10-15 minutes. Investigator KWS (Black female-identified) also conducted a portion of the interviews. Investigators were mindful of racial and gender discordance, respectively, but this barrier was in part overcome by practicing cultural sensitivity, employing interpersonal skills, and demonstrating authenticity to build trust [44][45][46]. Probing questions were used throughout interviews to encourage expansion on responses. Audio files from interviews were recorded using unique identifiers to maintain confidentiality, uploaded to a secure server, and later manually transcribed verbatim by TC and EB (white femaleidentified). Transcriptions were uploaded to Dedoose, a secure, web-based program for qualitative data management and analysis [47].

Qualitative analysis
An inductive thematic analysis was conducted using Braun and Clarke's framework [48]. Research on the perceptions of Black Americans undergoing PAD screening and education -particularly in communitybased settings -is virtually non-existent. As such, an inductive approach allowed for the data itself (i.e., the lived experiences of Black Americans) to inform the generation of theory. The codebook was developed using an inductive approach, with the codes directly derived from interpretations of the qualitative data itself [49]. Team members (TC, EB, KWS) independently read through all transcripts and engaged in reflexive journaling, identifying common patterns in the data that helped guide the formulation of a preliminary codebook. Meaningful, exemplar excerpts related to the study objectives were identified while reviewing the transcripts; these were used to create categories of data from which codes were developed. Coders (TC and EB) met regularly to discuss codes and definitions to ensure codes had explicit boundaries, were not interchangeable nor redundant [50], and tested the codebook using a representative sample of transcripts. KWS served as an external check on the research process to ensure credibility (i.e., trustworthiness) of the data by checking preliminary findings against raw data and personal observations during study administration [51]. Upon reaching consensus on the final codebook (see Additional file 2), coders independently coded all 28 transcripts. Coded excerpts were adjudicated at team meetings until 100% agreement was achieved. The final coded excerpts were reviewed to generate themes based on corresponding data. Proposed themes were adjudicated during team meetings until consensus was reached. If a theme was observed by only one coder, then data were reviewed to ensure themes were semantic or explicit rather than latent or interpretive [50]. Finally, once themes were adjudicated, the team read through each transcript to ensure the final themes were representative of the dataset. Quantitative data collected during study visits were reviewed for the purposes of triangulation [52].

Results
A total of 37 participants were enrolled in the study, and 28 participants completed the final visit and interview. The remaining study participants were lost-to-followup. The average age of participants was 59.3 ± 11.2 years, and most did not hold a high school graduate degree (Table 1). Nearly all participants (93%) reside in a zip code in Cleveland, Ohio with socioeconomic needs greater than the national average, as determined by Dignity Health's Community Needs Index (CNI) [53] (see How often do you come to this barbershop now? More than twice a month 13 (46) Once or twice a month 13 (46) Less than once a month 2 (7) Additional file 3). Quantitative results from the clinical measurements in the larger pilot study are published elsewhere [42], but a summary of the results as it relates to this sub-study is provided here: Of those who completed the final visit, a total of 4/28 (14%) had a clinically significant value (ABI ≤ 0.90), none of whom were previously aware of their PAD diagnosis. 19/28 participants (68%) had hypertension, defined as at least two values of systolic blood pressure of ≥130 and/or diastolic blood pressure of ≥80 on at least two separate visits [54]. 8/19 (42%) were unaware of their hypertension diagnosis prior to the study. Seven main themes emerged from the data ( Table 2).

Motivation to seek healthcare among black men exists, yet barriers such as fear, trust, and access persist
A continuum of the propensity to engage with the healthcare system was identified among participants. Some described yielding autonomy to providers, while others avoided engaging in healthcare interactions altogether. Notable barriers to accessing care were fear and/or discomfort associated with the detection of clinically significant news.
"A lot of black males are frightened to get themselves checked out. They'd rather jump out of an airplane at 450,000 feet in the air, knowing that they have an operable parachute. " -Participant 15 (Age: 58).
The physical presence of a healthcare intervention in the community seemed to help overcome barriers associated with low propensity to engage with the healthcare system.
"If y'all out in the community, that might show somebody else that they shouldn't be afraid to get themselves checked out, because a lot of people don't come to the doctor… they're scared. " -Participant 1 (Age: 56).
Several participants conceptualized healthcare as primarily for emergencies, but some expressed that engaging with the study promoted follow-up with a healthcare provider. One participant without health insurance noted: While participants expressed motivation to engage with healthcare, they also described many socioeconomic challenges in addition to barriers to seeking care, including lack of trust in the healthcare system and scheduling or cost logistics (including lack of health insurance). Five participants (18%) self-reported experiencing discrimination previously while seeking healthcare. Additionally, only 19 participants (68%) have regular access to the internet, and seven participants (25%) reported having trouble getting food and groceries during the COVID-19 pandemic.
"Most people in the community gotta work as many hours as possible to make ends meet, so I don't have an extra two hours to go there, but I might have enough time to slide through 'cause I gotta get a haircut for where I'm working at… but I don't have time to go to the doctor. " -Participant 9 (Age: 46).

Knowledge about health status is empowering, reassuring, and precipitates health behavior change
Fourteen participants (50%) reported that they do not have a regular healthcare provider and only 19 (68%) participants reported having seen a primary care provider in the past year. This may have been exacerbated during the COVID-19 pandemic, given that 12 participants (43%) reported resisting seeking medical care or not going to the doctor for fear of contracting the virus, or that 7 participants (25%) reported their insurance being impacted by the pandemic. Many participants who do not regularly receive primary care noted that engaging with the study and learning about their health status was reassuring and increased accountability.

Convenience of accessing health care resources in the barbershop
Accessibility and comfort of the barbershop helps overcome barriers to seeking care, such as mistrust or fear of the healthcare system, time burden of regular visits, and socioeconomic barriers.

Community-based education intervention enhanced knowledge of cardiovascular disease
Across the participant population, awareness of PAD was generally low at the beginning of the study. Participants reported that information provided in the study helped to facilitate enhanced knowledge about PAD and chronic disease.
" Similarly, after learning about the adverse outcomes associated with tobacco use, including increased risk of hypertension and PAD, one participant highlighted his gratitude for quitting.

"[The study] gave me more of an insight…on how [PAD] affects…the Black community. By smoking and the high blood pressure just let me know that I'm very grateful that I quit smoking. " -Participant 8 (Age: 63).
While there was a general consensus that the study facilitated enhanced medical knowledge among participants, there were notable opportunities for improvement. Importantly, some participants expressed that medical jargon occasionally stood in the way of knowledge gain, and some content was incongruent with prerequisite health literacy.
"Not saying all the complicated medical terms [makes it more understandable] … if you're going to talk to a patient, break it down to layman's terms. " -Participant 36 (Age: 48).
These findings highlight the need to modify future educational materials, tailoring them to individuals of differing levels of healthcare literacy.

Convenience of accessing health care resources in the barbershop
Participants described the barbershop as a community hub for Black men that serves primarily as a gathering place. Several participants reported attending their respective barbershop for many years, and nearly all participants (92%) reported attending the barbershop at least once monthly.
"I've been coming down here since I was kid. So about the last forty some odd years, everybody gonna come to the barbershop for a haircut. They come for everything else. The haircut just happen to happen. " -Participant 9 (Age: 46).
Several participants described the compounding economic and healthcare access challenges that the Black community faces and spoke about the utility of health screenings in the barbershop setting.
"Some Black people here…never see the doctor because they don't have insurance, they don't have a car, they don't have nothing. But if you say, "Go to barbershop, " they can walk, come to the barbershop. " -Participant 13 (Age: 55).

Despite disparities, participants advocate for health of community
Several participants expressed the influence role models have in shaping community health. All participants expressed satisfaction with health screenings and most encouraged the study team to continue initiatives for the betterment of the community.

Positive study feedback provided by participants
Most participants described positive experiences and generally denied discomfort or burden with study procedures such as the ABI test, although some noted the need for a larger space in the barbershop for study procedures. While compensation was helpful to some, particularly during the COVID-19 pandemic, when asked whether the compensation provided by the study was appropriate, participants described their concerns for the community.
"…You guys are helping the community, and I'm hand in hand with you guys. Some people don't have no doctor or nothing like that. " -Participant 1 (Age: 56).

Discussion
Peripheral artery disease (PAD) disproportionately burdens Black Americans [14,20], heightening the risk of poor health outcomes, including reduced quality of life, major cardiovascular events (i.e., heart attack, stroke), and limb amputation [10,55]. The seven themes identified in this qualitative study demonstrate that barbershop-based PAD screenings are perceived to be acceptable among Black men, and may help facilitate early disease detection.
While recognition for the importance of communitybased participatory research interventions exists [56], few have explored perceptions among patrons in barbershop interventions. Our first aim was to assess the acceptability of barbershop-based screening for PAD. The overwhelmingly positive feedback among study participants supports the acceptability of barbershop-based PAD screenings. This is notable, considering that ABI testing, just one component of our study, requires more time than health screenings employed in other barbershop-based interventions, such as blood pressure measurements and glucose checks [56,57]. Participants noted several factors important for successful implementation, including a large, private space to conduct ABI testing and information delivery tailored to individual health literacy. Further, community was identified as a beacon of health among our study population, and existing social cohesion within barbershops seemed to facilitate enhanced participant engagement, consistent with prior literature [58]. Both the physical presence of a health intervention in a trustworthy location and the buy-in from barbers and community members as role models may have helped to overcome barriers to healthcareseeking behavior associated with historic mistrust or fear. The pervasive support expressed by participants contrasts with previous findings, where only 11.8% of Black men reported feeling comfortable undergoing barbershop-based education and screenings via trained barbers [59], although screenings in this study were conducted by healthcare professionals. While prior studies demonstrate improved disease management with barbers as health educators [37,38], future research should explore participants' acceptance of this model involving healthcare professionals in the barbershop setting. Further, while only one participant explicitly mentioned the word "racist, " the various socioeconomic challenges described by participants [28], disparities in rates of PAD and its associated impacts on, and low propensity to engage with preventative healthcare [19,60], are likely associated with systemic racism. Similarly, while participants described fear as a barrier to seeking healthcare, it was unclear whether fear is associated with masculinity, or perceived or experienced discrimination in healthcare. Given that interpersonal and systemic racism persist, future research should more intentionally and explicitly explore participants' perceptions as it relates to interpersonal and systemic racism.
Our second aim was to assess participants' perceived awareness of PAD. Most participants stated they had minimal awareness of PAD prior to the intervention and reported aspirational lifestyle modifications after learning about PAD, including smoking cessation. This is noteworthy given the high prevalence (57%) of smoking among our study population. Even for participants with normal clinical values, the knowledge gained about PAD served as a catalyst for raising awareness in the community about the disease, being mindful of lifestyle choices, and engaging in preventative care. These findings highlight the need for additional community-based PAD education and screening initiatives. Consistent with prior studies [61,62], participants frequently described reserving interactions with the healthcare system for emergency situations. This study seemed to expand conceptualization of healthcare to include preventative care, evidenced by participants' reported increased engagement in preventative care. Additional community-based initiatives that highlight the importance of preventative care and exposure to health-promoting norms may help improve health outcomes among this population [63,64], including early detection of PAD. However, while building trust and delivering culturally competent education may help to detect and initiate treatment for PAD, an onus should also be placed on healthcare, public health institutions, and governments to address individuals' social needs and improve community conditions to correct historical injustices that contribute to disparate CVD outcomes.
Lessons gleaned from this study may inform future community-based interventions for CVD. First, participants expressed that barbershop-based screening helped overcome barriers to seeking care, including fear or a lack of trust associated with the healthcare system, socioeconomic challenges, and a low propensity to access preventative care -barriers previously described as unique challenges for Black men [60,63,65]. Future research should explore factors that negatively affect Black Americans' experiences with or perceptions of healthcare, including fear and mistrust potentially associated with providers' implicit biases or historical injustices toward Black Americans [30,32,33]. As such, community members should be involved in designing and implementing community-based research studies. Finally, although individual health was highly valued among our study population, considerable external determinants of health beyond individuals' control were noted throughout. Therefore, efforts to prevent and address individuals' social needs may prove to be promising in mitigating health disparities. Further efforts should be made to understand and address social determinants of health and to eradicate barriers that stand in the way of the cardiovascular health of Black men.

Limitations
There were several limitations to our study. Given that we used an inductive approach to explore semantic themes strictly representative of the entire dataset, it is possible that a different or larger sample of individuals may have allowed for better exploration of minor, latent themes. Additionally, it is possible that participants were not entirely forthcoming or that the racial discordance between the interviewer (TC) or gender discordance between the interviewer (KWS) and participants impacted their responses, as well as initial recruitment in the study [45]. As a means to overcome this, KWS -who shared racial concordance with participants -served as a primary contact, led study recruitment, and oversaw all study activities while TC (male-identified) conducted most of the interviews and allowed for fluid conversation in gender concordant contexts. The qualitative researchers (TC and EB) acknowledge inevitably held implicit biases about the study population and were committed throughout both study visits and analysis to confronting, mitigating, and discussing these biases. Given that those who participated in an interview attended multiple study visits and completed the study, it is possible that the views and experiences synthesized do not represent those who may not have valued this method of screening, or those who were lost to follow-up or unwilling to consent to the feasibility study. Therefore, our results may be favorably biased and may not be generalizable to all participants in the study or to the greater population. Finally, participants did not provide feedback on the themes identified, and we did not include barber or other stakeholder responses as a measure of acceptability; future research should explore the perspectives of these key stakeholders.

Conclusions
This qualitative study highlights the perspectives of Black men who participated in a barbershop-based research study involving screening for and education about PAD. Findings support the acceptability of implementing barbershop-based PAD education and screening. Participants demonstrated increased knowledge of PAD and provided insights into both barriers and facilitators of health and healthcare-seeking behavior, as well as the barbershop as a cultural institution. These insights may help guide the implementation of future barbershop-based interventions, as well as other community-based screening and education initiatives.